Rights at Risk

Map of Mississippi

Top 20 Mississippi County HIV Rates
and Corresponding Poverty Rates

I. Executive Summary

Donna M. is homeless and living with HIV in Jackson,
Mississippi. In a conversation with Human Rights Watch, she described how the
intense stigma surrounding HIV in Jackson made living without housing an even
more frightening experience. Even when Donna lived with relatives, fear that
her HIV infection would be discovered kept her from being treated:

First I tore the labels off [my medicines], then I ended up
throwing them away. I was scared [my family] would kick me out if they found
them.

Robert B. is a gay man living with HIV near Jackson. He lost
many of his health benefits after he moved from New York, but he also endures
the constant pressure of homophobia.

Being gay with HIV in Mississippi is a terrible curse. I
came here from New York and it is like going back 40 years in time. Everyone
treats you like dirt.

More than 1.1 million people
in the United States are living with HIV and an estimated 56,000 people become
newly infected each year. Some of the highest HIV infection and AIDS death
rates in the US are found in southern states such as Mississippi, where Donna
M. and Robert B. are struggling for survival. Mississippi not only fails to
invest in HIV/AIDS prevention and care, it also promotes punitive,
stigmatizing, and discriminatory policies that undermine efforts to reach the
populations most vulnerable to HIV. Mississippi has actively resisted increased
federal funding for HIV/AIDS programs and services. This report presents the
voices of people living with HIV in Mississippi and highlights state responses
that leave people with HIV/AIDS without treatment at rates comparable to those
in Botswana, Ethiopia, and Rwanda.

From Jefferson county in
the West to Noxubee county in the East, a picture emerges in Mississippi of
people with HIV and AIDS unable to meet their basic needs including housing,
transportation, and access to health care. Despite these hardships,
Mississippi’s investment in HIV/AIDS programs and services remains
minimal. The state relies almost exclusively on federal programs to provide
care and services for HIV and AIDS. Despite clear evidence, often prepared by
its own state agencies, that relying on limited and incomplete federal programs
is not sufficient to meet Mississippians’ urgent needs, the state fails
to maximize the federal benefits it could receive for housing, medical care,
and other services vital for people living with HIV and AIDS. Most disturbing
is Governor Haley Barbour’s attempt to block health care reform that
would expand Medicaid benefits for people living with HIV in the state.

Throughout Mississippi,
people living with HIV, their advocates, health providers and public officials
describe an extreme stigma surrounding HIV that is, for many, more frightening
than the disease itself. Human Rights Watch found that Mississippi laws and
policies promote prejudice and discrimination against those vulnerable, and
perceived to be vulnerable, to HIV, thereby contributing to the problem.
Numerous legal provisions, including constitutional amendments, discriminate
against homosexuals and state sex education laws marginalize lesbian, gay,
bisexual, and transgender (LGBT) youth. In Mississippi, the criminal law
penalizes those with HIV for failing to disclose their positive status, an
approach that public health experts deem likely to undermine, rather than
promote, the public health.

Mississippi’s sex education policies also play a
harmful role in the state’s HIV epidemic. The state has the highest rates
of sexually transmitted disease (STD) and teen pregnancy in the nation and
alarming rates of HIV infection among young black men who have sex with men
(MSM). Yet Mississippi’s legislature remains stubbornly committed to failed
messages of abstinence in sex education, ignoring evidence that such approaches
have little effect on reducing HIV or STD transmission. Despite the fact that
students in Mississippi are having sex earlier than in any other state, the
state suppresses information about condom use and effectiveness in sex
education, denying youth access to accurate and relevant health information
that can prevent HIV infection.

The sex education curricula in Mississippi also mandates
negative messages about “homosexual activities,” creating hostile
school environments for LGBT youth and interfering with their right to health.
Combined with other state laws that discriminate against homosexuals,
Mississippi promotes a culture of homophobia that, according to state public
health officials, endangers the health of gay, bisexual, and other men who have
sex with men by keeping them away from HIV testing and treatment services.

The HIV/AIDS epidemic in the Southern US has been particularly
devastating for minority communities.Nowhere
is the dramatic racial impact of the epidemic more apparent than in the state
of Mississippi, where African-Americans are only 37.5 percent of the population,
but comprise 76 percent of those newly infected with HIV. Mississippi’s
failure to embrace evidence-based approaches in the face of increasing health
threats to minority populations conflicts with fundamental principles of human
rights.

An alarming rise in HIV infection among young black men who
have sex with men recently prompted an investigation by federal and state
health authorities, who recommended implementation of comprehensive sex
education at an early age in order to increase awareness of risk and to promote
condom use as a proven method of prevention. These recommendations have been
utterly ignored in the public schools despite evidence that once infected these
young men are unlikely to access adequate health care. Similarly, though
African-American women have the second-highest HIV infection rate in the state,
Mississippi’s “Just Wait” abstinence campaign does not
provide evidence-based HIV prevention education to this very vulnerable
population.

The factors identified in this report are not the only
contributors to the HIV epidemic in Mississippi, an impoverished state with
poor rates of overall health, education, and development. Stigma and
discrimination, fueled by community attitudes, religious beliefs, and other
societal forces are also contributing factors. But government action plays a
significant role, and the harmful policies highlighted here undermine efforts
to combat the HIV/AIDS epidemic and disregard national and international guidelines
on best practices for effective management of the disease. These policies
combine to create a high-risk environment where it is difficult for many people
to avoid HIV infection and to access life-saving treatment and support. If
there is to be meaningful progress in access to HIV services, Mississippi’s
obligation to protect public health and human rights should be the immediate
focus of both federal and state governments.

'

II. Recommendations

To the State of Mississippi

To the Governor of
Mississippi:

Support provisions of the Patient Protection and
Affordable Care Act of 2010 (health care reform legislation) that would
increase access to health services for people living with HIV/AIDS in
Mississippi, including expansion of community health centers, improvement
of access to health care providers, and expanded eligibility for Medicaid.

To the Mississippi
State Legislature:

Increase state investment in HIV/AIDS prevention, care,
and essential services such as housing and transportation.

Expand the income eligibility threshold for Medicaid and
expand HIV-related benefits and services including coverage for drug
dependence treatment and increased coverage for prescription drugs.

Ensure that state agencies are authorized to maximize
federal funding for HIV-related services including Medicaid, HIV prevention,
housing, and transportation.

Repeal statutory requirements for abstinence-only sex and
HIV education and replace them with requirements for comprehensive sex
education that includes scientifically accurate information about HIV/AIDS
and condoms as a method of prevention and ensures that teachers,
administrators, and other state officials are not permitted to restrict
accurate information about HIV prevention. Ensure that all sex and
HIV/AIDS education materials are inclusive of lesbian, gay, bisexual, and
transgender youth.

Repeal HIV-specific criminal laws that penalize behavior related
to HIV disclosure, exposure, and transmission in light of evidence that
these laws undermine public health and human rights.

Repeal statutory prohibitions on adoption by homosexuals.

Repeal the constitutional amendment banning marriage
between couples of the same sex.

Increase support for legal services for low-income
residents including those living with HIV and AIDS.

To the Mississippi Department of Health:

Take all necessary steps to ensure that department policy
reflects a commitment to protect the human rights of all who come into
contact with the STD/HIV Office or other public health services, including
the establishment of a Patient’s Bill of Rights, the revision of all
relevant forms to comply with human rights standards, the improvement of
training and supervision of Disease Intervention Specialists (DISs) and
other Department of Health employees, the establishment of a consumer
advisory board, and the realization of other recommendations set forth in
the report prepared by the State Health Access Research Project (SHARP).

Increase efforts to maximize federal funding for HIV/AIDS
prevention, treatment, and essential services such as housing and
transportation.

To the Mississippi Department
of Human Services:

Ensure adequate access to affordable services for sexual
and reproductive health. Terminate the “Just Wait” abstinence
program and replace it with comprehensive sex education that includes complete,
scientifically accurate information about HIV/AIDS and other sexually
transmitted diseases.

To the Office of
Mississippi Medicaid:

Increase the income eligibility threshold to ensure
adequate access to health services for low-income people living with
HIV/AIDS.

Repeal the state requirement for face-to-face interviews
for initial and continued Medicaid eligibility.

Support the expanded income eligibility for Medicaid
provided by the Patient Protection and Affordable Care Act of 2010. Apply
for a waiver under section 1115 of the Social Security Act to receive
federal matching funds for immediate expansion of Medicaid to people
living with HIV who are not disabled.

To the United States Government

To the Congress of the
United States:

Ensure adequate funding for implementation of the National
AIDS Strategy including improved access to prevention, treatment, and
essential services such as housing and transportation.

Ensure adequate HIV/AIDS funding for all regions and
ensure that funds for both medical care and housing are targeted to
regions, states, and communities that reflect current epidemiological data
and where prevention, treatment, and essential services such as housing
and transportation are most needed.

Repeal legislation
supporting or funding abstinence-only education and continue to support
and fund comprehensive sex education that includes scientifically accurate
information about HIV/AIDS and the use of condoms as a method of
prevention. Ensure that all such materials are inclusive of lesbian, gay,
bisexual, and transgender youth.

To federal agencies
including the US Centers for Disease Control and Prevention, Office of National
AIDS Policy, and Department of Health and Human Services:

Establish clear policy guidelines regarding laws that
criminalize behavior related to HIV disclosure, exposure, and transmission
to ensure public awareness that these laws undermine public health and
human rights while failing to promote either public health or criminal
justice. Provide technical assistance to states to repeal and/or revise
these laws as recommended in the National AIDS Strategy.

Continue the current
trend away from funding abstinence-only education and ensure that adequate
guidelines, funding, and technical assistance are available at the state
and local levels to provide comprehensive sex education that includes scientifically
accurate information about HIV/AIDS and condoms as a method of prevention.

Consider establishing a “race to the top”
program, similar to that in place for education in the United States, that
provides financial incentives for states whose HIV/AIDS policies result in
measurable progress while complying with public health and human rights
standards.

To the United Nations

To the United Nations Committees on Human Rights, Economic, Social and Cultural
Rights, and Racial Discrimination; and to the United Nations Special
Rapporteurs on the Right to the Highest Attainable Standard of Health and
Contemporary forms of Racism, Racial Discrimination, Xenophobia and Related
Intolerance; and the United Nations Human Rights Council:

Call upon the United States to comply with its international
obligations to eliminate disparate racial impact in public health
including the disparate racial impact of the HIV/AIDS epidemic.

Call upon the United States to improve oversight,
establish incentives, and take other necessary steps to ensure compliance
with human rights obligations at the state and local level.

III. Methodology

The research for this
report originated as part of a larger project focused on human rights
violations related to HIV/AIDS in the southern United States. For that project
hundreds of individuals were interviewed throughout the South during the period
July 2009-October 2010.In December 2010 Human
Rights Watch released the briefing paper “Southern Exposure: HIV and
Human Rights in the Southern United States” highlighting the intersection
of socio-economic conditions and human rights abuses that make that region the
nation’s epicenter of HIV/AIDS. Because socio-economic conditions and
policies in Mississippi exemplify many of the findings of that report, the more
than 65 interviews conducted in Mississippi became the subject of this report. Human
Rights Watch interviewed approximately 40 people living with HIV/AIDS, both
individually and in groups, with all interviews occurring with the consent of
all participants. Pseudonyms are used for all people living with HIV quoted in
the report in order to protect their privacy and confidentiality.

Human Rights Watch also
interviewed HIV advocates and employees of HIV service organizations, health
care providers, HIV case workers, public health officials, state legislators,
teachers, and members of the judiciary. The Mississippi Department of Health
cooperated fully with Human Rights Watch and provided planning and other
documents for review. All documents referenced in this report are publicly
available or on file with Human Rights Watch.

The findings of the report were discussed with the State
Health Officer and staff of the STD/HIV Office of the Department of Health
while the report was still in draft form. Human Rights Watch repeatedly requested
meetings with the Office of the Governor to discuss the findings of the report
but received no response.

IV. Background

HIV/AIDS continues to
pose a major public health threat in the United States. Every nine-and-a-half
minutes someone in the US is infected with HIV; 56,000 people are newly
infected each year. More than 1.1 million people are living with HIV, and
almost half of Americans know someone infected with the virus.[1]AIDS is caused by the human immunodeficiency virus, or
HIV. HIV progressively destroys the body's ability to fight infections and
certain cancers by killing cells in the immune system called CD4+ T (CD4) cells.
Regular monitoring of CD4 cells and the amount of HIV in the body, or viral
load, is essential to determining appropriate treatment. Antiretroviral therapy
(ART) treats HIV with a combination of medications, each of which attacks the
virus's life cycle in a different way. Based on laboratory test results,
doctors also prescribe different prophylactic drugs to prevent patients from
developing opportunistic infections such as pneumocystis pneumonia (PCP).[2]

A key aspect to achieving the benefit of ART is full
adherence to the therapy regimen. Due to the rapid multiplication and mutation
rate of HIV and other factors, very high levels of adherence to antiretroviral
schedules are necessary to avoid viral resistance. In comparison with patients
who are adherent to ART, non-adherent people have higher mortality rates, less
improvement in CD4 cell count, and spend more days in the hospital. Viral
resistance not only affects the health of the individual but also that of the
community, as resistant strains can be transmitted to others.[3]

In the United States, racial and ethnic minorities bear the
overwhelming burden of the disease. Comprising just 13 percent of the US
population, 46 percent of people living with HIV/AIDS are black. Blacks are
disproportionately represented in every transmission category, including men
who have sex with men, women, heterosexual men, injection drug users, and
children.[4]
The President’s Office of National AIDS Policy has called the toll of the
epidemic on the black community “staggering.”[5]
Latinos and Asian-Pacific Islanders also have rates of HIV infection out of
proportion to their numbers in the general population.[6]

The South is at the epicenter of the HIV epidemic in the
United States,[7] with more people living with HIV
and dying of AIDS than in any region in the country. The South has:

the highest rates of new infections,

the most AIDS deaths,

and the largest numbers of adults and adolescents living
with HIV/AIDS.[8]

Though only 36 percent of the US population lives in the
region, about half of people living with HIV or AIDS in the US live in the
South.[9]

HIV has had a particularly devastating impact on minorities
in the South. In southern states such as Alabama, Louisiana, Georgia, and
Mississippi, blacks comprise approximately 30 percent of the population but have
65-75 percent of HIV cases.[10]
Of the 10 states with the highest rates of new HIV diagnosis for Latinos, seven
are in the South.[11]

People living with HIV in
the South die of AIDS at a higher rate than in other regions.[12] A
recent study found that being black, female, and living in the South were all
associated with “substantially higher rates of death from AIDS”
than in other geographic areas including other countries such as Canada,
Australia, and Brazil.[13] In the South, many people are diagnosed with HIV
late in the progression of the disease, at or near the point of full-blown
AIDS, when treatment is less effective.[14] In many southern states, including Mississippi,
more than half of people who test positive for HIV do not get adequate care.
This is significantly higher than the national percentage of 33 percent of
people living with HIV who are not in care.[15]

The concentration of the HIV epidemic in the South is not
new or sudden: between 2000 and 2003 the number of AIDS cases rose 35.6 percent
in the six states that comprise the Deep South, while rising 5.2 percent
nationally.[16]
By 2003 the South led the country in people living with HIV, people dying of
AIDS, and diagnoses of AIDS.[17]
Yet federal funding for HIV/AIDS, chronically inadequate to address the
nation’s epidemic, has shortchanged the southern region for decades by
relying on a formula based on cumulative AIDS cases, including deaths from the
disease since the 1980s, rather than targeting money toward areas with rising
rates of infection.[18]
The Obama Administration’s National AIDS Strategy acknowledges this
problem and declares an intention to rectify it, but it remains to be seen whether
that intention will translate into a revised funding formula or the equally
important goal of adequate funding for HIV nationally.[19]
Moreover, changes in federal policy alone are not enough. In many states in the
South, socio-economic conditions combine with discriminatory, stigmatizing, or
ineffective state laws and policies that are incompatible with human rights and
put people at risk for HIV infection or exclude them from care.[20]
Strong federal and state leadership is required to address state policies if
the goals of the National AIDS Policy are to be realized.

HIV/AIDS in Mississippi

Mississippi is a state of
2.9 million people living in 82 counties. More than half of the population
lives in rural areas, and Jackson, the largest city, has fewer than 250,000
people.[21] Mississippi is not a healthy state. Mississippi
ranked last of 50 states and the District of Columbia in two recent evaluations
of “overall health” that examined a wide variety of factors
including poverty and access to health care, quality of care, education levels
and health literacy, obesity and nutrition, infant mortality, and life
expectancy.[22] On a “human development” index that
rated factors such as capability to earn an adequate living, to make decisions
about one’s own life, to have access to quality education and health
care, enjoy cultural liberty, and live free from fear and violence, Mississippi
ranked lowest of 50 states. Moreover, the index was marked by significant
racial disparities, with levels of education, health, and income for
African-Americans well below those of white residents of the state.[23]

Mississippi is one of the poorest states in the nation.
Median household income in Mississippi was $36,646 in 2009, well below the
national median of $50,221.[24] One in
five people live below the federal poverty line ($22,000 in annual income for a
family of four), the most of any state in the country.[25]
In some economically depressed counties of the Mississippi Delta almost half of
the population (48 percent) live below the federal poverty level.[26]
In Mississippi, 28 percent of children live at or below the poverty level,
compared to 19 percent nationwide.[27] Blacks
live in poverty at three times the rate of whites.[28]
Compared to 14 percent of whites, 43 percent of black children live in poor
families.[29]

Poverty is strongly linked with health disparities in the
United States, as low-income people have less access to health coverage, less
stable housing, and less healthy environments.[30] Poverty
particularly impacts people with HIV as higher rates of homelessness, poor
overall health, and drug dependence often combine with lack of access to health
care to raise the risk of infection and produce significantly worse outcomes in
HIV-positive persons, particularly in the South.[31]

The US Centers for Disease Control and Prevention (CDC)
recently found that heterosexuals living in urban poverty are five times more
likely to be HIV-positive than their wealthier counterparts, citing the
importance of factors such as homelessness and lack of access to health care as
critical obstacles to HIV prevention efforts. The CDC study recommended a
similar study of HIV and poverty in rural areas, particularly in the South
where rural poverty and HIV rates are high.[32]

The Mississippi Department of Health in the State
Comprehensive HIV/AIDS Plan for 2009 recognized the impact of poverty on HIV:

The link between low economic status and HIV risk
exacerbates the existing barriers of effective behavioral intervention,
testing, early diagnosis and early intervention for newly infected persons.[33]

Mississippi has the 10th highest rate of AIDS
diagnosis among US states and the 16th highest rate of diagnosis of
HIV.[34]In 2009 the state had 9,212people living with HIV or AIDS.[35]According to the Mississippi Department of Health, this figure
underestimates the HIV/AIDS population, as 10-25 percent of people living with
HIV in the state are considered to be unaware of their status.[36]
The number of people living with HIV or AIDS in the state increased nearly 5
percent during the period 2007- 2009. The number will continue to rise as the
advent of antiretroviral therapy reduces deaths from the disease, as will the
need for a range of HIV-related services.

Racial and ethnic disparities in HIV/AIDS are dramatic in
the state. Blacks comprise 37.5 percent of the population, but 72 percent of
Mississippians living with HIV/AIDS are African-Americans. Of newly diagnosed
HIV infections, 76 percent are in African-Americans. The death rate from HIV
among African-Americans is 10 times that of whites. Among the Hispanic
population, Hispanic males are infected at a rate four times that of whites,
and Hispanic females are infected at a rate eight times that of whites.[37]

The largest proportion of HIV cases are diagnosed in men who
have sex with men. Women having sex with men are the next largest category of
infection; injection drug users are the smallest category.[38]
Overall, the epidemic in Mississippi has remained relatively stable since 2000,
with minor changes in the number of new cases diagnosed each year in the last
decade. Specific populations, however, have seen variations in the rates of
infection. For example, HIV cases among women, both white and African-American,
have reduced in the last several years.[39]

However, Mississippi has seen an alarming rise in the number
of HIV cases among young black men who have sex with men. Between 2005 and 2007
the cases of HIV diagnosed in black men ages 13-31 increased by 48 percent.[40]
This prompted an investigation in 2008 by the CDC and the Mississippi Department
of Health. The investigation found high rates of unprotected anal sex combined
with low rates of awareness of potential risk of HIV infection. The majority of
HIV-infected men who participated in the study was also uninsured, had no
primary health care provider, and was unlikely to have been previously tested
for HIV.[41]

Most people living with
HIV in Mississippi are in the 25-44 year old age group. But Mississippi’s
epidemic is becoming younger, as 13-24 year olds have replaced 45-64 year olds
as the state’s second-largest category of both new infections and people
living with HIV.[42]

Many Mississippians living with HIV are not receiving
treatment. The US Health Research and Services Administration (HRSA) requires
each state receiving federal HIV/AIDS funding to report an estimate of
“unmet need” for HIV care and services. This is defined as the
percentage of people who have been tested for HIV and are aware of their status
but have not received basic health care services for HIV.[43]
In Mississippi, estimates of “unmet need” are at least 50 percent,
significantly higher than the national average of 33 percent.[44]
The Director of Mississippi’s STD/HIV Office said:

Save yourself a transatlantic airline fare to a developing
country. Just come to Mississippi, where we have a vast underserved population.[45]

In Mississippi, the percentage of people with HIV not
receiving care or support services is comparable to that in Botswana, Ethiopia,
and Rwanda.[46]

V. Findings

Living with HIV/AIDS in
Mississippi

Poverty

A fundamental principle of human rights law is that everyone
is entitled to a standard of living adequate for his or her health and
well-being.[47] Throughout
Mississippi, Human Rights Watch spoke with people living with HIV who were
struggling with extreme poverty. In a state where the median rent is $626 per
month,[48] many have
difficulty making ends meet, staying on medications, and maintaining their
health.

Sheila R. and her
husband Roy, for example, live outside of Canton, Mississippi. Both are living
with HIV; Roy has AIDS and is in a wheelchair. Their only monthly income is
$694 from Roy’s Social Security Disability payment; Sheila has been
unable to work due to her health problems, but she is not eligible for
disability as she does not have full-blown AIDS. Sheila and Roy receive primary
medical care from the Ryan White clinic in Canton, but she relies on donations
from pharmaceutical companies for her medications. Sheila told Human Rights
Watch:

We are trying to get by
on Roy’s disability. We got some rent support but it ended after 21
weeks, and since then life has been a day to day struggle. We don’t get
help with our utilities. We survive by the grace of God but not much else.[49]

Tyrone L. is a 33-year-old
man living with HIV in the Mississippi Delta, near the town of Clarksdale. Tyrone
lives on his $694 monthly disability check and $62 in food stamps. When Human
Rights Watch interviewed Tyrone, he was in distress because his disability
check had not arrived on the first of the month. It was now near the end of the
month and he had missed some of his HIV medications, a serious risk to the
health of persons with HIV. Tyrone stated:

I don’t feel so good. I’ve missed at least a
week of medicine. There is a three dollar co-payment for the drugs but I
can’t afford it. I had to walk a mile to the clinic. There used to be a
van but not anymore.[50]

The Mississippi State HIV/AIDS Plan confirms that poverty
and poverty-related issues such as unstable housing and lack of transportation
prevents people with HIV in Mississippi from accessing medical care and other
essential services. One health clinic reported basic communication as a primary
problem, stating that they cannot reach clients because their cell phones are
constantly being disconnected.[51]

The director of the STD/HIV Office in Mississippi identified
poverty as perhaps the greatest obstacle to the Department of Health’s
HIV efforts, stating, “People can’t prioritize HIV when they are
suffering from crushing poverty. Food, clothing and shelter come first.”[52]

Housing

Housing is also a fundamental human right, critical to
dignity, survival, and the ability to protect one’s health.[53]
It is well established that housing is particularly important for HIV
prevention and for the health of people living with HIV/AIDS.[54]
Homeless individuals living with HIV die at a rate five times higher than those
who are housed.[55] In
addition, stable housing supports HIV prevention efforts as it reduces drug use
and increases access to mental health services and other social assistance.[56]
The federal government recognizes the crucial role of housing to people living
with HIV in the National AIDS Strategy which states:

Individuals who lack stable housing are more likely to
delay HIV care, have poorer access to regular care, are less likely to receive
optimal antiretroviral therapy, and are less likely to adhere to therapy.[57]

People living with HIV in Mississippi face severe housing
problems. The Mississippi Department of Health has identified significant
shortfalls in short-term, long-term, and emergency housing for the HIV/AIDS
population.[58] The
Mississippi Development Authority (MDA), the state agency responsible for
housing and community development, has declared that “housing is the
greatest unmet service need among people living with HIV/AIDS.”[59]

Mississippians living with HIV described how unstable
housing affected their health. Donna M. described her fear when she was staying
with relatives that they would discover her HIV medications:

First I tore the labels off [my medicines], then I ended up
throwing them away. I was scared [my family] would kick me out if they found
them.[60]

Michael J. was living on the streets before he found
transitional housing at Grace House in Jackson. Michael told Human Rights
Watch:

It’s tough to be homeless. I saw lots of folks in the
shelters out there who are real sick with the virus, you can tell. They look
grey and they’re wasting away. I would have been one of them if I
hadn’t found Grace House.[61]

Lack of Access to Health Care

The right to health requires medical care to be accessible
to all, available in the community, and acceptable in quality.[62]
Yet in Mississippi, 50-70 percent of people living with HIV and aware of their
status are not receiving even a minimal level of medical care. Those that are
receiving treatment still face a range of barriers to adequate services that
include restricted benefits, provider shortages, and significant transportation
challenges.

In Mississippi, 18
percent of people are without health insurance, a figure comparable to the
national average of 17 percent.[63] Minorities, however, are much more likely to be
uninsured, as 22 percent of African-Americans and 48 percent of Hispanics are
without insurance, compared to 17 percent of whites.[64] People living with HIV/AIDS in Mississippi
without health insurance have two options: the Medicaid program or services
provided under the Ryan White Act.[65]

Medicaid is the joint federal/state health insurance program
intended to provide a “safety net” to adults and children who meet
income eligibility requirements and meet other eligibility criteria such as
belonging to certain groups, e.g. pregnant women, blind, aged, or disabled.[66]
States are largely permitted to set their own income eligibility requirements resulting
in significant variations among the 50 states.[67] Eligibility
thresholds set by the state of Mississippi are among the lowest in the nation,
leaving many ineligible for Medicaid.[68]

For people living with HIV, Medicaid is more accurately
characterized as providing disability coverage rather than health insurance, as
they are eligible only when their condition advances to full-blown AIDS and
becomes disabling. This is a restriction set by the federal government, though
states may apply for a waiver in order to provide coverage for HIV before it
advances to AIDS.[69] Because
Mississippi has not done so, many people with HIV but not AIDS are not eligible
for Medicaid. For example, Roy R. was on Medicaid because he was ill enough to
be in a wheelchair, but his wife Sheila, also HIV-positive and on antiretroviral
medication, was not eligible.[70]

Those who do qualify for Medicaid face the additional
challenge of restricted benefits. States have substantial discretion to set the
Medicaid benefit package, and benefits in Mississippi are among the most
limited in the nation for all recipients, including those with HIV/AIDS.[71]
Mississippi Medicaid, for example, does not cover physical or occupational
therapy, non-emergency dental care, psychologist services, dentures, speech
therapy, prosthetic or orthotic devices, or hearing aids. Mississippi Medicaid
does not cover drug dependence treatment other than short-term detoxification.
This restriction has particular impact on people living with HIV, a population
with a high level of substance abuse disorders and for whom injection drug use
can be a primary route of HIV transmission.[72] As
stated by Adam, a man living with HIV in the Jackson area:

You have to have money
for drug treatment. There are no free beds for rehab.[73]

Mississippi limits people on Medicaid to five prescription
drugs per month, though HIV/AIDS medication regimens often exceed this limit.[74]
Joseph, a man living with HIV/AIDS who moved recently from Louisiana to Mississippi,
told Human Rights Watch:

Uninsured people living
with HIV/AIDS who do not meet both the disability and the income requirements
for Medicaid must turn to services provided by the Ryan White Act.[76] The Ryan White program is the country’s
largest federally funded initiative specifically for people living with
HIV/AIDS. Ryan White provides care and services to those without other sources
of insurance coverage or ability to pay. In Mississippi, 1,300 people living
with HIV/AIDS received services through Ryan White programs in 2009.[77] The majority of Ryan White clinical services,
however, are located in the metropolitan Jackson area, creating transportation
issues for more rural residents. The state Department of Health opened several
additional clinics since 2008 in an effort to address this problem, but access
for many remains limited. For example, five counties in southwest Mississippi
are provided no Ryan White coverage at all.[78]

In Mississippi, 19.6 percent of the population reports
“not being able to see a doctor because of cost,” the
second-highest percentage in the nation.[79] The
scarcity of doctors in the state compounds the problem of affordability. In
2008, 31.9 percent of Mississippians were living in primary care “health
professional shortage areas (HPSAs)” compared to 11.8 percent nationally.
Of the 82 counties in the state, 74 are HPSAs in whole or in part.[80]
Mississippi is one of eight states in which over 40 percent of the population
is “medically disenfranchised,” meaning they have inadequate or no
access to primary care physicians.[81]

The shortage of health care providers is particularly acute
for people living with HIV, as there are fewer than 30 infectious disease
specialists in the state of Mississippi and most of them practice in the
Jackson area.[82] Lisa M.
told Human Rights Watch that she travels 52 miles to her current doctor, but
“the biggest problem is keeping a doctor at all. This is my fifth doctor
in one year.”[83]

Human Rights Watch also heard numerous stories of physicians
unwilling to treat people with HIV. An HIV case manager at the Crossroads
Clinic in Greenville, Mississippi, stated that she had a client in need of
gynecological services:

I called 20 gynecologists and all of them said flat-out no
when I told them she was HIV-positive. I have also been turned down by
podiatrists. A lot of stigma is coming from doctors themselves.[84]

A case worker at one Ryan White clinic stated that many
doctors have stopped taking HIV patients. There is currently a wait of three to
four months for an appointment at her clinic for someone living with HIV.[85]

Mississippi’s predominantly rural population and a
shortage of health facilities make transport a serious problem for people
living with HIV. Debbie H., age 44, has HIV and lives near Olive Branch,
Mississippi. Many in the Olive Branch area go to Memphis, Tennessee, for their
HIV care, as it is the closest Ryan White clinic. Debbie told Human Rights
Watch:

I travel 75 miles to see my doctor. Sometimes I get help
from the Department of Health social worker for HIV/AIDS who will pick people
up in her own car. But she has nine counties to cover all by herself.[86]

The Hispanic community is terrified to come into care or
enter the Health Department for fear of being deported. Also we can’t
find interpreters to help them when they do come in; we pay so little that
nobody will work as an interpreter.[87]

Stigma and Discrimination

Stigma, defined as “a mark or sign of disgrace,”[88]
is deeply entrenched in Mississippi in relation to HIV and AIDS. People living
with HIV/AIDS, medical personnel, public health officials and community
activists consistently identified pervasive stigma as one of the primary
barriers to prevention, care, and treatment in the state. Donna M. threw away
her medications while staying with relatives when she was homeless for fear
that they would evict her if they knew she had HIV.[89]

The problem of stigma is discussed extensively in the state
HIV/AIDS plan prepared by the Department of Health:

Many Mississippians fear being thought to have or known to
have HIV far more than they fear the disease itself. Such over-arching fear
prevents effective behavioral interventions from being received and practiced,
limits the number of citizens seeking HIV testing, and decreases the likelihood
of remaining in care after diagnosis.[90]

“HIV stigma,” however, is often an overly narrow
concept. Behind negative attitudes toward people with HIV is often prejudice
and discrimination against groups vulnerable, or perceived to be vulnerable, to
the disease, including African-Americans, gay men, prisoners, sex workers, and
drug users.

June J., a 37-year-old woman living with HIV near Olive
Branch, Mississippi, said, “The stigma is so bad that if you have HIV
you’re either a drug user or a whore.”[91]

“Being gay with HIV in Mississippi is a terrible
curse,” said Robert B., a 48-year old man living with HIV. “I came
here from New York and it is like going back 40 years in time. Everyone treats
you like dirt.”[92]

Joseph P., a 40-year-old man living with HIV in Jackson,
Mississippi, described stigma as a fear based on ignorance. “People
don’t want to touch me. They think they can get it from shaking
hands.”[93]

Stigma exacerbates transportation problems as many people
told Human Rights Watch that they were unwilling to seek health services at the
facility closest to their home for fear of losing confidentiality. Tammie Woodall,
an HIV nurse specialist at an HIV clinic near Greenville, Mississippi,
expressed surprise that half of her patients were from the local area. “That
is unusual; the stigma makes people travel long distances for their
care.”[94]

Ruby Gray, an HIV case worker in Canton, Mississippi,
stated:

Stigma is the number one problem. We can’t educate
the families because the clients won’t tell them they have HIV.[95]

Gray went on to describe a terrible irony of HIV stigma in
Mississippi:

They’re isolated, depressed. Lots of times we are
actually treating the family member too, but neither one knows.[96]

Thomas L., now living in Jackson but originally from the
Mississippi Delta, said, “People in my hometown would rather die than
have anybody know they have AIDS. When people do die they say it was
cancer.”[97]

Lack of Affordable Legal Services

Human Rights Watch and
others have documented the importance of access to legal services to protect
the rights and health of people living with HIV.[98] People living with HIV often face legal issues
related to their HIV status including access to health benefits,
discrimination, and the need for estate planning documents. For low income
people with HIV, the ability to resolve legal problems related to basic
necessities such as food and shelter are critical to staying healthy and
maintaining adherence to medications.[99] A recent survey of people living with HIV/AIDS in
Mississippi found that 63 percent needed legal assistance with housing issues,
while another 53 percent had legal needs in the area of employment
discrimination.[100]

Josephine B., a woman in Clarksdale, Mississippi, said that her
children had been taken away by their grandmother because she “was afraid
I’d give them HIV.”[101] Susan
R. told Human Rights Watch that “I tried to get into a mental health
center but they wouldn’t admit me because I’ve got HIV.”[102]
Several others had been denied benefits, perhaps incorrectly, but had no idea
how to pursue an appeal.[103]

Yet individuals who have
suffered discrimination on the basis of HIV status or disability, sexual
orientation, race, gender, or religious discrimination have limited recourse in
Mississippi. There is no state anti-discrimination law; rather, individuals
must attempt to enforce federal laws.[104] The Americans with Disabilities Act prohibits
discrimination against people living with HIV,[105] but the ability to pursue a complaint in court
is difficult. In Mississippi there is a severe shortage of legal services for
those who cannot afford a private attorney. The Access to Justice Commission, a
body convened by the Mississippi Supreme Court, found that Mississippi ranked
49th of 50 states in funding for civil legal services for low-income
people.[106]

According to the Commission, Mississippi relies almost
exclusively on shrinking federal funding to provide legal assistance in the
state, leaving many underserved. The commission estimated that a legal services
system that now serves 15,000 people per year would need to serve 200,000
people per year to meet the demand.[107] The commission
found that state funding should be increased and the State Bar should improve
and expand its pro bono services programs.[108] This
would be particularly important for people living with HIV, many of whom are
unable to pursue remedies for discrimination or claims for health insurance and
other public benefits without the assistance of counsel. The necessity of legal
services for people with HIV is noted in the National AIDS Strategy:

People with competing demands and challenges meeting their
basic needs for housing, food and child care often have problems staying in
care. Access to legal services can be important to help people resolve issues
with discrimination, access to public benefits including health care, and
resolving problems with employment and other issues that can create serious
barriers to staying in care.[109]

State Responses to the HIV Epidemic in Mississippi

The number of new HIV infections has stabilized, but Mississippi’s
HIV/AIDS epidemic is not subsiding; rather, as one population stabilizes its
rate of infection, infections increase among others. Every year, more people
are living with HIV and AIDS in Mississippi as medications increase life
expectancy. The demand for a wide range of services related to HIV continues to
increase.

In Mississippi, the state continues to rely almost
exclusively on limited and incomplete federal programs to address its HIV
epidemic, despite clear evidence that this approach fails to meet the urgent
needs of Mississippi’s HIV-positive residents. It also opposes programs
that would expand access to health care for people living with HIV. At the same
time, the state continues to implement policies that have been proven
ineffective or counterproductive for reducing HIV infection and that undermine
human rights.

Failure to Invest in
Programs for People Living with HIV/AIDS

Mississippi received $27 million in 2009 from the federal
government for HIV prevention, care, and treatment.[110]
These, and funds from previous years, have been utilized by the state
Department of Health to support a network of medical providers, social workers,
and prevention programs throughout the state.[111]
But Mississippi’s own state agencies provide ample documentation that the
state’s current approach fails to meet the pressing needs of a very
vulnerable population. The 2009 State Comprehensive HIV/AIDS Plan finds that
half of the state’s HIV-positive population is not in care, and
identifies access to health services, AIDS Drugs Assistance Program (ADAP)
medication adherence, and medical transportation as areas of urgent unmet need.[112]
The plan states:

Public health in Mississippi is consistently under-funded
and providers in Mississippi are challenged with caring for increasing numbers
of non-insured/under-insured patients in the face of shrinking budgets and
increasing medical costs.[113]

The state housing
authority has identified housing as “the greatest unmet need for persons
living with HIV” in the state.[114] Yet in Mississippi the state HIV/AIDS allocation
has remained under $1 million since 1997, and it has never provided funds for
housing or for transportation.[115] Reluctant to invest state funds, Mississippi depends
on limited and incomplete federal government programs for prevention, care, and
services for people with HIV, despite the knowledge that this approach leaves many
without essential services or adequate care.

Housing

In Mississippi, the state provides no funding for housing
services targeted to people living with HIV/AIDS. All funding for HIV-related
housing assistance comes from the federal government, primarily under the
Housing Opportunities for Persons with AIDS (HOPWA) program.[116]
HOPWA offers emergency, short-term and long-term rental assistance programs for
people living with HIV/AIDS through programs administered by the states.[117]
Mississippi’s reliance on federal funding to house people with HIV/AIDS
leaves many without coverage, as federal programs are limited. Like Ryan White,
HOPWA’s funding formula is based on cumulative AIDS cases rather than
rates of new infections, an approach that leaves many southern states,
including Mississippi, with funding levels that fail to account for high rates
of new HIV and AIDS diagnosis.[118] In
addition, HOPWA provides no services for the homeless; in order to be eligible
for HOPWA assistance one must be already housed.

HOPWA funding provided help to 494 individuals with HIV in
Mississippi between 2008 and 2009.[119] Mississippi
limits its HOPWA program to short-term rental assistance that supplements
rental payments for only 21 weeks per calendar year. A handful of hospice
residents also receive HOPWA assistance but for the majority of Mississippians
with HIV, only 21 weeks of rental assistance is available.[120]
Mississippi does not participate in HOPWA programs that provide funds for
longer-term help with rent or permanent housing for people living with HIV.[121]

Another source of federal funding for people living with HIV
is the Ryan White Act, but this statute permits states to use only 25 percent
of the funds received for housing, as it is not considered a “core
medical service.”[122]
Mississippi’s reliance on federal programs that are limited, incomplete,
and clearly do not meet the demand leaves many people living with HIV facing
chronic housing issues. Mississippi’s failure to apply for all available
federal funds compounds an already urgent problem. The Mississippi Development
Authority, the state housing and community development agency, estimates that
in the next five years, more than 3,500 people with HIV/AIDS, nearly 40 percent
of Mississippi’s known HIV population, will have unmet housing needs. The
MDA recommends increasing state participation in HOPWA to provide more medium
and long-term housing options.[123]

Ella Tardy is Director of Grace House in Jackson, one of the
state’s three transitional housing programs that together provide housing
for approximately 30 people in Mississippi. According to Ms. Tardy, these small
programs try to maximize federal funding sources including HOPWA, funds from
the Department of Housing and Urban Development, and the Ryan White program,
but she says:

The state is failing to
squeeze out federal dollars and is not investing in HIV housing itself. This
leaves us with a world of challenges here in Mississippi.[124]

Health Care

Mississippi’s Medicaid program could be a lifeline for
many low income people living with HIV. Nationally, 36 percent of people living
with HIV are on Medicaid and another 14 percent are on a combination of
Medicaid and Medicare, the government insurance program for the elderly.[125]
But Mississippi’s restricted eligibility limits exclude many people with
HIV from the program. The state has ranked last in national surveys of Medicaid
programs for more than 20 years as a result of its low eligibility thresholds
and restricted benefits.[126] Mississippi
sets the income maximum for Medicaid eligibility at 46 percent of the Federal
Poverty Level (FPL) or $845 per month for a working family of four,
significantly more restrictive than the national average of 66 percent of the
FPL. For jobless parents, the maximum is even lower at 25 percent of the
Federal Poverty Level or $459 a month for a family of four.[127]This is significantly lower than the average
for all regions of the US, even the South, as indicated in the graph below.

Maximum Income for Medicaid
Eligibility for a Jobless Family of Four[128]

These rules put Medicaid
out of reach for many people living with HIV/AIDS, as do burdensome eligibility
procedures. Mississippi is the only state in the nation to require face-to-face
meetings for initiating and continuing Medicaid eligibility. Recognized as a
significant barrier to enrollment, these requirements have been eliminated in
every other state but were praised by Governor Haley Barbour as a “key
factor” in removing 100,000 people from the Medicaid rolls in the last
six years.[129] Legislation proposed in 2010 would have
eliminated the face-to-face requirement for re-enrollment, but the bill died in
committee.[130]

As an impoverished state, Mississippi receives the
nation’s highest level of federal matching funds for its Medicaid
program, with the federal government contributing more than three dollars for
every dollar spent by the state.[131] Yet
Mississippi fails to maximize this favorable ratio, spending a thousand dollars
less per individual on Medicaid than the national average.[132]
The District Health Officer for the Mississippi Delta, a region with the
state’s highest poverty and second-highest number of residents living
with HIV/AIDS, described his state’s resistance to investment in
Medicaid:

We get three dollars for every dollar we put into Medicaid,
but that still means having to put a dollar in. The state doesn’t want to
do it.[133]

There are Ryan White clinics for people living with HIV who
are not eligible for Medicaid, but transportation for those living in a
predominantly rural state is a major barrier. Mississippi’s public health
officials identify transportation as an urgent need, but the state has never
contributed to transportation for people living with HIV.[134]
The Ryan White statute prohibits the use of more than 25 percent of grant
monies for transportation,[135] leaving
many with the burden of walking long distances, paying for gas out of tight
budgets, or hoping for a ride. Reliance on limited federal funds for health
care transportation leaves many without services that are critical to residents
of a rural state.

Access to medication is also tenuous for people with HIV in
Mississippi. The Ryan White Act includes ADAP that provides antiretroviral and
other essential medications for people who are uninsured or underinsured and
meet income eligibility requirements.[136] ADAP
relies on annual federal appropriations and voluntary state funding
contributions. Each state administers its own ADAP and can determine, in large
part, eligibility standards and benefits provided.[137]
In Mississippi, 1,274 persons received HIV/AIDS medications through ADAP in
2007. ADAP enrollment reflects the racial disparity of HIV and AIDS, as 76
percent of Mississippi ADAP clients are African-Americans.[138]

Unlike the Medicaid
threshold, Mississippi’s ADAP eligibility standards and number of
prescription drugs offered to clients are comparable to those of other states.[139] The current recession and resulting unemployment
has increased demand for the ADAP program, and in many states waiting lists
have developed due to shortages of federal and state funding.[140] As of December 2010 there was no ADAP waiting
list in Mississippi, but the state is considering cost containment measures
that may limit eligibility and benefits.[141] The state last made a contribution to ADAP in
1997, when there was an emergency waiting list, but has made no contribution to
ADAP since.[142] Recently, fears have arisen among state
policymakers that limited state HIV funding may have to be used for ADAP as
demand for the program increases.

The current budget allocation for Fiscal Year 2011 -12 for
HIV/AIDS is $700,000 to be administered by the Department of Health and an
additional $50,000 to be divided between two AIDS service organizations. This
money was appropriated from a state budget totaling $5 billion, as part of a
public health appropriation of $31 million.[143] The HIV/AIDS
appropriation has been $750,000 for several years, an amount that the Department
of Health STD/HIV Office has used to support salaries for its employees as well
as supplemental contracts for prevention and treatment services.[144]
According to public health officials, increased pressure on ADAP would require
transfer of these funds to ADAP to prevent a waiting list, an outcome that
state officials are hopeful can be avoided. Under this “either/or”
scenario created by scant state funding, transfer of this allocation for ADAP
would leave the STD/HIV Office without its only source of state support.[145]

Federal health care reform legislation, enacted in March
2010,[146] will
help to address several of the significant problems facing people living with
HIV in Mississippi. Health care reform will provide additional funding for
health care professionals in underserved areas and for expansion of community
health centers.[147] Health
care reform will also expand eligibility for Medicaid to all persons living at
or below 133 percent of the federal poverty level whether they are
“disabled” or not. This will benefit people living with HIV/AIDS,
particularly in the South, the region where the highest numbers of people will
become newly eligible.[148] These
reforms do not take effect until 2014. States may apply for early expansion of
Medicaid, with federal matching funds, to cover the period 2010-2014, but
Mississippi has not done so.[149]

Indeed, whether Mississippi will take advantage of any of these
opportunities is highly uncertain. As part of Governor Barbour’s commitment
to “keeping government small,” the state has taken an aggressive
stance in opposing health care reform, joining 17 other states in a lawsuit
seeking to enjoin its implementation on constitutional grounds.[150]
In 2009 Mississippi also rejected $56 million in federal stimulus funds that
could have provided unemployment benefits to many Mississippi residents.[151]
Tax structures ensure that state funds remain limited; state and local tax
revenues in Mississippi are the fifth-lowest in the nation, with every individual
and corporation earning $10,000 and over paying the same five percent rate of
income tax.[152]

A comprehensive fiscal or health policy analysis is beyond
the scope of this report; however, governments have an obligation to implement
health programs in a non-discriminatory manner and to use available resources
to protect the right to health.[153] The
current economic climate clearly puts additional pressures on state budgets,
but Mississippi’s lack of investment in HIV/AIDS services predates the
recession. Funding decisions in the state deserve further scrutiny,
particularly given the extremely disproportionate burden on minorities that
results. The state’s revenue and spending practices should prompt the
question of whether Mississippi is doing everything it reasonably can to improve
health care and services for people living with HIV/AIDS.

Denial of Comprehensive
Sex and HIV/AIDS Information in Schools

More than 47,000 young people between 13 and 24 years are
currently living with HIV/AIDS in the US.[154] In the
age group 13-19 years, 70 percent of all HIV/AIDS diagnoses in 2006 were among
black youth, primarily by sexual transmission. Among black and Latino men who
have sex with men, the group with the most cases of HIV/AIDS in the US, the
majority of new infections are occurring in the youngest age group, ages 13-29
years.[155] Among
women (and among black and Latina women), six of ten new infections occur among
women in the youngest age group.[156]

Sexually transmitted diseases such as gonorrhea, chlamydia,
and syphilis can double the risk of acquiring HIV infection.[157]
In 2008, Mississippi ranked number one in both chlamydia and gonorrhea rates
among the 50 states. Mississippi ranked in the top 10 in rates of syphilis,
with a rate that has more than tripled since 2004.[158]
These diseases affect African-American women and girls in Mississippi
disproportionately. For example, 62 percent of women with chlamydia in
Mississippi are African-Americans. Almost half are in the age group 10-19, and
of these, 61 percent are African-American girls.[159]
Sixty eight percent of girls 10-19 with gonorrhea in Mississippi are
African-American.[160] Mississippi
also ranks first in the nation in rates of teen pregnancy, an indicator of high
levels of unprotected sexual activity among youth.[161]

Lois B., a 17-year-old high school student in Jackson,
Mississippi, said:

There are lots of pregnant girls in my school and kids who
have STDs and HIV. They drop out.[162]

The promotion of abstinence-only sex education continues in
many states despite little evidence that it prevents HIV/AIDS or other sexually
transmitted diseases.[163]
Education programs that emphasize abstinence while restricting discussion of
condoms suppress important HIV prevention evidence and impede the right of
students to potentially life-saving information.[164]
Human Rights Watch has documented the negative consequences and human rights
concerns raised by government-mandated abstinence-only programs both
internationally and in the United States.[165] Since
1998 the federal government has distributed more than $50 million annually to
the states for abstinence-only education programs primarily through the vehicle
of welfare reform legislation.[166]

In 2010 the Obama administration and Congress eliminated
two-thirds of federal funding for these programs and appropriated $190 million
for comprehensive sex education initiatives.[167] This
approach acknowledged the findings of federal public health authorities that
abstinence-only education does not reduce sexual activity among youth.[168]
Abstinence-only education is not recommended by the CDC Task Force on Community
Preventive Services, which found “insufficient evidence of its
effectiveness” in preventing pregnancy in adolescents as well as sexually
transmitted diseases including HIV/AIDS. The task force recommends
“comprehensive risk reduction” education that may or may not
include abstinence but which directly addresses use of contraceptive devices
such as condoms and may include condom distribution and demonstration.[169]
One recent study found abstinence education to be effective in delaying sexual
behavior of students in grades six to eight. However, the curriculum did not
disparage condoms and did not present marriage as the only acceptable format for
a sexual relationship.[170]

In Mississippi, rates of sexual activity among young people
are significantly higher than the national average. While 46 percent of high
school students nationally report having had sex at least once, 61 percent of Mississippi
high school students report having done so.[171]Mississippi also reports the highest rates
of teens having sex before the age of 13.[172] Yet
Mississippi law does not require sex education or HIV/AIDS education to be
taught in the schools. If schools choose to present such instruction, the law
requires that “abstinence shall be the state standard for any sex-related
education taught in the public schools.”[173]
The law requires no discussion of condoms as a mode of protection against
sexually transmitted disease or unwanted pregnancy, but if condoms are
discussed, no directions can be given as to their use:

The discussion may include contraceptives but only if such
discussion includes a discussion of the risks (failure rates, diseases not
protected against). In no case shall there be a demonstration of how condoms or
any other contraceptives are applied.[174]

Tanya A., 16, a high school student from Jackson, felt
strongly about the need for open discussion of condoms:

These classes that talk about abstinence, they don’t
inform you how to protect yourself.[175]

HIV/AIDS may be taught in schools, but the suggested
curriculum is “designed to support disease prevention and unintended
pregnancy through abstinence education.”[176]
An HIV/AIDS advocate from the Mississippi Delta, a region where sexually
transmitted diseases are among the highest in the state, told Human Rights
Watch:

I went to the high school to talk about HIV and the kids
wanted condoms. They asked me for them but I told them I couldn’t give
them out. It was really a shame.[177]

Mississippi education law contains other provisions that
might permit local school boards to adopt alternatives. If passed by majority
vote, school boards may adopt a curriculum that is not abstinence-only.[178]
However, state law also states that any alternative curriculum must not
contradict any suggested component of the abstinence curriculum.[179]
In addition, Mississippi does require general health education and the
suggested materials for the health curriculum include sections on HIV, AIDS,
and sexually transmitted diseases for students of appropriate age.[180]
But this curriculum does not mention condoms or ways to prevent transmission
other than abstinence.[181]

The numerous and often conflicting rules, guidelines, and
recommendations leave sex and HIV education largely to local discretion.
HIV/AIDS advocates and public health officials said that in reality, the
existence and content of sex, HIV, and health education classes depends on
individual principals and teachers and varies widely throughout the state.

Nsombi Lambright, Executive Director of the American Civil
Liberties Union (ACLU) of Mississippi, described the pressure on school
personnel who believe in providing more comprehensive sex education:

In Mississippi sex education is determined school by
school, principal by principal, with progressive teachers willing to put their
jobs on the line.[182]

Juanita Davis, Director of HIV/STD Prevention and Education
at the Mississippi Department of Health, stated:

What we can say is a matter for each principal and local
school. Some invite us to talk and we can be free about what we tell the kids.
Others are non-cooperative. There is a need for more AIDS education in the
schools, there is a lot of misinformation, like you can get it from a mosquito.[183]

Mary L., age 16 and a high school student told Human Rights
Watch:

Kids need information
about HIV; they don’t know how you can and can’t get it.[184]

Human Rights Watch interviews with students from four public
high schools in Jackson revealed that there was no sex education at all in two
of the schools, while students in the other two received sex education that
talked about abstinence with no discussion of condoms.[185]
One student at a school where sex education was not part of the standard
curriculum stated that she received an hour of HIV education in a childhood
development course. However, many students “opted out” of the class
on that day, utilizing an option provided to parents for all sex education
classes in the state.[186]

The mixed messages will continue in 2011. The Mississippi
Department of Health applied for and received federal dollars for 2011 to
implement a teen pregnancy program that incorporates comprehensive sex
education rather than emphasizing only abstinence.[187]
This is a positive step, but until the state repeals laws that require the
promotion of abstinence and restrict discussion of condoms, the lack of
comprehensive sex education will continue to endanger the health of a young, sexually-active
population.

The state’s commitment to abstinence education is
particularly dangerous for young men who have sex with men, the highest risk
group for HIV infection in Mississippi. The alarming increase in HIV infection
among young African-American men who have sex with men prompted an
investigation and a formal study in 2008 by the Centers for Disease Control and
Preventions and the Mississippi Department of Health. Recommendations from the
study emphasized the need for early intervention during adolescence with
information stressing the importance of condom use for preventing transmission,
recommendations that have been utterly ignored by the public schools.[188]

The sex education policies also carry, and in some cases
mandate, negative messages about homosexuality that harm lesbian, gay, bisexual
and transgender youth. Mississippi law requires discussions of sex education to
teach “that a mutually faithful, monogamous relationship in the context
of marriage is the only appropriate setting for sexual intercourse.”[189]
The law further states that such discussions must teach “current state
law re: rape, statutory rape, paternity, establishment of child support and
homosexual activity.”[190] The state
law regarding “homosexual activity” is the anti-sodomy law that
remains on the books despite the ruling of the US Supreme Court in 2003
declaring such laws to be unconstitutional.[191]
Mississippi criminal law section 97-29-59 declares it a crime punishable by one
to ten years in prison to engage in a “detestable and abominable crime
against nature,” interpreted to include the crime of sodomy.[192]

Teaching that positive, healthy sexuality only occurs in
heterosexual marriage renders alternative sexuality invisible and fails to
protect the right of LGBT youth to relevant and necessary health information. Mandating
anti-homosexual messages in the schools discriminates against LGBT youth and creates
a hostile school environment that conflicts with their right to an education
free of discrimination.[193] Research
by the Gay, Lesbian and Straight Education Network has found that in schools
that promote abstinence-only sex education, LGBT youth experience higher levels
of victimization and lack of physical safety then in school than in schools
where sex education is not abstinence-only.[194] Though
there is no evidence of a directly causal effect, this association is a matter
of concern.

Mississippi’s education laws are part of a larger
government-sponsored abstinence campaign that has been fueled by federal
dollars in the last decade, most recently $4.7 million between 2008 and 2009.[195]
The Mississippi Department of Human Services describes its “Just
Wait” abstinence campaign:

Mississippi has one of the highest percentages of births to
teens in the nation. Although the teen pregnancy rate is decreasing in
Mississippi, it is still a significant problem—one which has a definite
impact on the state's welfare rolls. In an effort to assist with this serious
problem, the Mississippi Department of Human Services (MDHS) established the
“Just Wait” Abstinence Unit within the Division of Economic
Assistance. The sole purpose of the unit is to address the issue of out-of-wedlock
births, teen pregnancy and other "at risk" behavior of Mississippi's
young people.[196]

The “Just Wait” program is problematic from the
perspectives of both health and human rights. Although the program description
mentions “at-risk” sexual behaviors, it makes no mention of HIV or
other sexually transmitted diseases. There is an online link to one “fact
sheet” that warns of HIV and STDs, but nowhere on the “Just
Wait” program website are condoms referenced, nor is there a reference or
link to the Department of Health or its HIV/STD unit. Rather, the program goals
are to involve churches, government, and the media in encouraging abstinence
outside of marriage and helping young people “discover that the only safe
answer is abstinence.”[197]

Given that the overwhelming majority of people on
Mississippi’s “welfare rolls,” officially known as the
Temporary Assistance for Needy Families (TANF) program, are African-American
women,[198]
targeting this group for state-sponsored abstinence messages raises concerns of
interference with the right to reproductive freedom.[199]
The involvement of religious institutions in the campaign raised civil rights
concerns among US legal advocates as well. In 2009 the “Just Wait”
program used federal funding to hold a public rally for abstinence led by
religious leaders in Jackson, Mississippi, that was challenged by the ACLU on US
constitutional grounds as a failure to separate church and state.[200]
Most disturbing is the denial of information relating to HIV and other sexually
transmitted diseases to African-American women, a group so heavily impacted by
these infections in Mississippi.

State-Sponsored Homophobia

Nationally, gay and bisexual men comprise two percent of the
US population yet account for 53 percent of new HIV infections each year.[201]
Gay, bisexual, and other men who have sex with men are the group “most
severely affected” by the HIV epidemic and the only group in which
infections have been rising steadily since the 1990s.[202]The
Mississippi State HIV/AIDS Plan reports that men who have sex with men are the
leading exposure category for rates of new infection and for individuals living
with HIV/AIDS.[203]

In relation to HIV and AIDS, homophobia can be dangerous to
one’s health. Public health officials in Mississippi cite the extreme
stigma surrounding homosexuality as a primary factor in avoidance of testing
and care among men who have sex with men, the group with the highest infection
rates in the state.[204]
“Men who have sex with men are an extremely hard to reach population,”
said Juanita Davis of the Department of Health. “There is so much stigma
that they do not want to come forward.”[205]

The State Comprehensive HIV/AIDS Plan addresses the
impact of homophobia on HIV prevention and treatment:

Stigma connected to sexual orientation may lead men who
have sex with men to be secretive about their sexual behaviors and less likely
to practice risk reduction. Due to pervasive social mores many MSM also engage
in sex with women in addition to sex with their male partners.[206]

In 2008 local HIV advocates challenged the Mississippi
Department of Health’s failure to apply for federal funds available from
the US Centers for Disease Control and Prevention that would permit them to
target the MSM population for testing and prevention programs.[207]
Since then, the Department of Health has shown an improved response to the
needs of this population by allocating 41 percent of community-based prevention
funds in 2009 to groups that are targeting men who have sex with men.[208]

Prevention funding
alone, however, is not an adequate response. The state of Mississippi
contributes to stigma and homophobia with discriminatory criminal and family
law. Criminal laws that call sodomy “a detestable and abominable crime
against nature” are not enforceable under federal law yet they remain in
the criminal code and continue to be referenced in the state education code as
mandatory subject matter for Mississippi youth. Mississippi is the only state
in the union that expressly bars gay people from adopting children.[209]

In 2004 Mississippi
amended its Constitution in order to invalidate any attempt by lesbians or gay
men to marry.[210] The legislative sponsor of the amendment,
Representative Alan Nunnelee, called for voters to approve the measure as gay
marriage “goes against everything society has ever stood for.”[211] Nunnelee also opposed developing a school
curriculum that addressed homosexuality, calling the materials proposed for
combating homophobia “trash.”[212] Nunnelee was recently elected to the US House of
Representatives from Mississippi.

State Representative John Hines of the 50th
District, a strong advocate for the HIV/AIDS community, said homophobia was a
major barrier to improving state support for people with HIV and AIDS. Hines told
Human Rights Watch:

Legislators in Mississippi don’t see it as a public
health crisis; they see it as punishment for an unhealthy lifestyle.[213]

I’ve been called
a nigger and a faggot by state legislators right in the Capitol.[214]

Public health officials rightly express concern about the
willingness of gay and bisexual men to come forward to access health services.
But this public health problem is part of a larger political context. As long
as the state government continues to promote negative and discriminatory
policies that create a hostile environment for LGBT people, men who have sex
with men will continue to be what the Department of Health calls a “hard
to reach population” at significant risk to their health.[215]

Use of the Criminal Law
to Address HIV

Mississippi is one of 34 states that criminalize behavior
related to HIV exposure or transmission.[216] The
majority of these statutes impose liability on persons who are aware of their
HIV status and fail to disclose it to their sexual partner. In many states
transmission is not required for conviction, and, in the majority of cases
prosecuted under these laws, transmission has not occurred.[217]
Under Mississippi criminal law, the “knowing exposure” of another
to HIV is a felony punishable by 3-10 years in prison.[218]
Neither intent to transmit HIV nor actual transmission is required. In 2008 a
woman was prosecuted under this provision and subjected to house arrest for one
year for failure to inform her husband of her HIV-positive status. No
transmission of HIV occurred in this case.[219]

In addition, willful violation of an order issued by the
local public health officer while “afflicted with a life-threatening
communicable disease” is a felony punishable by five years in prison and
a $5,000 fine.[220] In
1998 a man received positive HIV test results and was instructed by a Disease
Intervention Specialist at the Department of Public Health to refrain from
activity that might transmit HIV. He signed a “quarantine order” to
this effect. His sexual partners were notified of his status and, months later,
one partner came forward to accuse him of engaging in sex without informing the
partner of his HIV status. The man was sentenced to five years in prison for
violating the quarantine order.[221]

Targeting people with HIV for penalties related to their sexual
behavior is problematic for both health and human rights. Because other
criminal laws prohibit acting against another person with intentional harm,[222]
laws that single out people with HIV are unnecessary and discriminatory. These
laws may have been expected to increase communication between sexual partners
thereby reducing transmission but there is no evidence to support this. Imposing
harsher penalties on those who are aware of their HIV status may discourage HIV
testing and diminish an individual’s willingness to seek care and
services.[223] In
addition, studies conducted in the United Kingdom have found that some gay men
are less likely to insist on condom use with a partner whom they perceive as
being under a legal duty to disclose his HIV status, as they assume he will
comply with the law.[224]

Criminal HIV laws have been criticized by international and
domestic public health authorities. The joint United Nations Programme on
HIV/AIDS (UNAIDS) found little evidence that criminal statutes promote either
criminal justice or prevention of HIV transmission.[225]

The US National AIDS Strategy cited a recent study
indicating that people with HIV do not change their behavior in states with
HIV-specific criminal laws,[226] stating:

The continued existence and enforcement of these laws may
run counter to scientific evidence about routes of HIV transmission and may
undermine the public health goals of promoting HIV screening and treatment.[227]

The Department of Justice has agreed to report on the
implications of HIV-specific criminal laws for people living with HIV and to work
with states considering changes to criminal statutes in order to “align
laws and policies with public health principles.”[228]

In the midst of an HIV/AIDS epidemic, Mississippi cannot
afford policies that have the potential to drive persons with HIV away from
testing and treatment. The Department of Health estimates that at least one-quarter
of HIV cases are undiagnosed,[229] and
50-70 percent of people who are aware that they have HIV are not in care.[230]
Criminal laws represent a punitive approach to HIV on the part of the state
that threatens to deepen fear, stigma, and exclusion for individuals with HIV.

Public Health Practices
That Undermine Human Rights

Under Mississippi law, individuals testing positive for HIV
shall be reported by name to the Department of Health.[231]
Individuals testing positive may also be subject to quarantine if such action
is deemed necessary. Those reasonably suspected of having HIV may be required
to submit to testing or quarantine and those who refuse may be prosecuted.[232]
Post-test counseling must be provided by law and other parties who may have
been exposed to HIV or other communicable diseases must be notified.[233]
For these purposes, the Mississippi Department of Health employs a team of
Disease Intervention Specialists. There have been objections from the HIV/AIDS
community to the practices of some DIS workers.

Human Rights Watch heard complaints ranging from
disrespectful treatment to breaches of confidentiality about the practices of
some DIS workers who were conducting follow up to positive HIV tests. According
to the Department of Health, the role of DIS workers is to explain positive
test results, inquire about sexual or drug-sharing partners who may be at risk,
and connect people to medical care and services.[234]
Some people, however, experienced the contact with DIS as threatening:

They came to my house and banged on the door, told me I
would be prosecuted if I didn’t show up for my interview. They scared me
to death.[235]

Others discovered their confidentiality had been breached:

One DIS guy came to find me at my job, and told my employer
why he was there. I was never able to go back there again, I never felt
comfortable. I gave up the job.[236]

Providers and case workers confirmed that complaints about
DIS workers were widespread:

The DIS experience can
be a nightmare. I have four clients who had terrible experiences where the DIS
worker came to their house and treated them very badly.[237]

A recent report found
after extensive interviews of people living with HIV in Mississippi that DIS
employees frequently had been disrespectful, harassing, and had sometimes threatened
people newly diagnosed with HIV and that such practices had turned people away
from essential services.[238] The report, conducted by the State Health Access
Research Project at Harvard Law School, recommended additional training on
federal confidentiality requirements under the Health Insurance Portability and
Accountability Act (HIPAA).[239] The report also recommended the establishment of
a consumer advisory board to the Department of Health that would serve as a
liaison between the department and the community of people living with HIV/AIDS
in Mississippi.[240] Department of Health officials acknowledged to
Human Rights Watch that the actions of some DIS workers may have been
problematic and have agreed to develop a Patient’s Bill of Rights as well
as to review training materials for the DIS employees.[241]

Human Rights Watch also received complaints about the form
used by DIS when interviewing people who had recently tested positive for HIV.
This form asks questions about previous HIV tests, number of sex partners, and
other topics reasonably related to public health surveillance. However, the
form also contains a checklist where the individual must indicate that he or
she has been counseled as to a number of “requirements” that
include “the necessity of not causing pregnancy or becoming pregnant.”[242]

The provision was interpreted by some people living with HIV
as a legal prohibition on pregnancy, as stated by Ruth T. in Olive Branch,
Mississippi:

I’m too old to worry about it, but after I signed the
form I called my friend and told her she couldn’t get pregnant. I wasn’t
even sure she could date.[243]

The ACLU of Mississippi has challenged this provision as
unlawful interference with the right to reproductive health and is currently
negotiating with the Department of Health for revisions to the form.[244]
The State Health Officer at the Department of Health Dr. Mary Currier assured
Human Rights Watch that the checklist has been recently removed from use and will
be revised to correct the impression that it is illegal to become pregnant in
Mississippi if you are HIV-positive.[245]

VI. Human Rights Obligations

Everyone has the right to a standard of living adequate for
the health and well-being of himself and of his family, including food,
clothing, housing, medical care, and necessary social services, and the right
to security in the event of unemployment, sickness, disability, widowhood, old
age, or other lack of livelihood in circumstances beyond his control.[246]

These principles from the Universal Declaration of Human
Rights establish that medical care, necessary social services, and housing are
integral components of human dignity, and are part of the claims all people
have to their right to an adequate standard of living. Housing has been
recognized as key to the realization of the right to health for all people,[247]
and protection of this right is particularly urgent for people living with HIV,
a fact acknowledged by both the US government and the State of Mississippi.[248]
Medical care should be accessible, available, and of adequate quality,[249]
a goal that remains out of reach for more than half of the people living with
HIV in Mississippi.

Moreover, the United States is obligated to address the
racial disparities that characterize the domestic HIV epidemic, a duty that is
fundamental to international and domestic human rights law, including the
International Convention on the Elimination of all forms of Racial
Discrimination (ICERD) to which the United States is a party.[250]
ICERD requires states parties, when the circumstances so warrant, to take
“special and concrete measures” to ensure the development and
protection of racial groups “for the purpose of guaranteeing them the
full and equal enjoyment of human rights and fundamental freedoms.”[251]
Moreover, under Article 5(e)(iv) of ICERD, the US is to eliminate racial
discrimination and guarantee to everyone, without distinction, the right to
public health.[252] The
treaty requires state parties to address not only intentional racial
discrimination but laws, policies, and practices that result in disparate
racial impact.[253]

In February 2008 the United States presented its periodic
report to the Committee for the Elimination of Racial Discrimination as
required under the treaty. Human Rights Watch and other NGOs submitted reports
to the Committee highlighting the health disparities based on race that have
worsened in the US over the last decade.[254] Human
Rights Watch specifically addressed the failure of the US government to
adequately address HIV/ AIDS, stating:

As HIV/AIDS rages through African-American communities, the
response of the US government ranges from neglect to undermining potential
solutions. There is no national HIV/AIDS plan and no comprehensive plan to
address the epidemic in minority communities. Medicaid, which offers health
insurance to low-income persons, denies eligibility until applicants are
disabled from full-blown AIDS. The Ryan White CARE Act and the AIDS Drug
Assistance Program (ADAP), designed to be "safety nets" for HIV/AIDS
patients denied Medicaid eligibility, are chronically under-funded. This gap
leaves many without access to medical care or life-saving medications. One in
five new HIV infections among African-Americans is a result of injection drug
use, yet the US government prohibits the use of federal funds for proven harm reduction
programs such as needle exchanges.[255]

In response to information provided by civil society as well
as by the United States, the committee issued concluding observations that
expressed concern about persistent racial disparities in health outcomes, access
to health care, and access to health insurance in the US.[256]
Moreover, the committee noted its continuing concern that the US lacks
sufficient mechanisms to ensure and coordinate implementation of the treaty at the
state and local levels.[257] Mississippi
has proven to be a case in point as the state’s failure to adequately
address HIV has placed an unacceptably high burden on the state’s
African-American population. Federal leadership is needed to ensure that state
policies that conflict with evidence-based national and international standards
for managing HIV are replaced with those that are compatible with human rights.

The Committee on Economic, Social and Cultural Rights has
interpreted article 12 of the International Covenant on Economic, Social and
Cultural Rights, to which the United States is not yet party, to obligate
states to take steps necessary for the “prevention, treatment and control
of epidemic, occupational and other diseases,” including the
“establishment of prevention and education programmes for
behavior-related health concerns such as sexually transmitted diseases, in
particular HIV/AIDS, and those adversely affecting reproductive health.”[258]
Mississippi’s state-wide abstinence campaign ignores the evidence that
such approaches have little effect on reducing HIV or STD transmission.
Suppression of information about condom use and effectiveness impedes the right
of students to accurate and relevant health information that is an essential
component of the right to health.[259]

Given the severe impact of sexually transmitted diseases, including
HIV, on African-American youth, Mississippi’s continued refusal to
endorse methods proven to reduce disease transmission conflicts with
obligations to address racially-based disparities in health. Promoting
abstinence-only messages to African-American women while failing to address
HIV/AIDS and other sexually transmitted infections is problematic in a
population heavily impacted by these infections.[260]

The sex education curricula in Mississippi that renders the
sexuality of LGBT youth invisible and mandates negative messages about
“homosexual activities,” interferes with the right to health of
LGBT youth, and creates school environments that are discriminatory and may be
unsafe. Combined with other laws and policies that discriminate against
homosexuals, Mississippi is responsible for state-sponsored homophobia that,
according to state public health officials, endangers the health and lives of
men who have sex with men by keeping them away from testing and treatment
services. These policies conflict with fundamental principles of human rights
including the right to health and the right to be free from discrimination on
the basis of sexual orientation.[261]

Laws that single out HIV exposure for criminal penalties are
unnecessary, discriminatory, and are considered by public health authorities as
likely to undermine, rather than promote, the public health. To their credit, Mississippi
public health officials have promised to revise practices that convey the
impression that the law prohibits people with HIV from causing pregnancy or
becoming pregnant. Development of a Patient’s Bill of Rights and improved
training for state employees would improve protection against breach of confidentiality
laws for people living with HIV.

VII. Conclusion

HIV and Human Rights in Mississippi:
An Environment of Risk

In Mississippi, harsh socio-economic
conditions place people at high risk of acquiring HIV and make it difficult to
access adequate treatment and support. Yet instead of promoting policies that
might ameliorate these conditions, Mississippi‘s response ranges from
inadequate support to actively opposing interventions that could make a
difference to the health and lives of its residents. Mississippi relies almost
exclusively on limited federal programs to provide HIV prevention, medical
care, housing, and transportation, but even with this approach the state fails
to maximize federal dollars that are available for these services. Federal
health care reform would expand access to health care for many Mississippians
living with HIV, but the state has joined a lawsuit to block its implementation.

At the same time,
Mississippi continues to ignore evidence-based recommendations for
comprehensive sex education, requiring abstinence before marriage to be the
primary message delivered to a student population that is reporting the highest
rates of sexually transmitted disease and teen pregnancy in the country. The
state criminalizes failure to disclose HIV status despite recommendations to
the contrary from national and international health and HIV experts. HIV
Infection among young black men who have sex with men is increasing at an
alarming rate, yet efforts to reach out to this population are undermined by
anti-gay laws and policies that keep them underground and away from public
health services.

The severe and disproportionate impact of these failed laws
and policies on African-Americans in Mississippi is highly problematic from a
human rights perspective. The US is obligated to address health disparities
based on race, an obligation that includes the duty to end ostensibly neutral
policies that nevertheless have a discriminatory impact on racial groups and to
ensure compliance at the state and local levels. Mississippi’s current
approach to HIV is inconsistent with both public health and human rights
imperatives.

The federal government bears the ultimate responsibility to
protect the right to health, ensure access to health services free from
discrimination, and to address racially-based health inequities. The goals of
the National AIDS Strategy will not be realized without improved federal
oversight of state approaches. Strong leadership, both federal and state, will
be needed to eliminate ineffective, stigmatizing, and discriminatory policies
that are placing health and life at risk in Mississippi.

VIII. Acknowledgements

This report was
researched and written by Megan McLemore, senior researcher with the Health and
Human Rights Division. The report was reviewed at Human Rights Watch by Joseph
Amon, Director of the Health and Human Rights Division, Rebecca Schleifer,
Director of Advocacy for the Health and Human Rights Division, Alison Parker,
Director of the US Program, Dinah Pokempner, General Counsel, and Babatunde
Olugboji, Deputy Program Director at the Program Office. Production assistance
was provided by Alex Gertner, Associate to the Health and Human Rights
Division, Grace Choi, Kathy Mills and Fitzroy Hepkins.

Human Rights Watch gratefully acknowledges the invaluable
assistance of Amy Rosenberg and Emily Broad of the State Health Access Research
Project; Robin Webb of A Brave New Day; Alonzo Dukes of the Southern AIDS
Commission; Rep. John Hines; the Mississippi Department of Health and the State
STD/HIV Office; Marilyn Moering of Building Bridges; Ella Tardy and Teresa Viramontez
of Grace House; Valencia Robinson; Nsombi Lambright, Bear Atwood and Nancy
Kohsin-Kintigh of the ACLU of Mississippi; Lisa Biagotti, and many others in
Mississippi who facilitated the research for this report.

Most of all, Human Rights Watch thanks the courageous men
and women living with HIV in Mississippi who shared their experiences for this
report.

Appendix

[1]
US Centers for Disease Control (CDC), Estimates of New HIV Infections in the
United States, August 2008; Hall, H., et al, “HIV Infection- United
States, 2005 and 2008,” in CDC, Morbidity and Mortality Weekly Report,
“CDC Health Disparities and Inequalities Report- United States
2011,” January 14, 2011, p. 87.

[2]
Department of Health and Human Services, Guidelines for the use of
Antiretroviral agents in HIV-1 infected adults and adolescents, January 2011.

[5]
G. Millett, Office of National AIDS Policy Blog, “White House Meeting on
Black Men and HIV,” June 4, 2010, http://www.whitehouse.gov/blog/2010/06/04/white-house-meeting-black-men-and-hiv
(accessed October 25, 2010).

[7]
As used in this report, “the South” refers to the 17 states of
Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky,
Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina,
Texas, Tennessee, Virginia and West Virginia, unless otherwise noted. This is
the definition utilized by the majority of primary reference databases cited in
this report including the US Centers for Disease Control and Prevention , the
US Census Bureau and the Kaiser Family Foundation HIV/AIDS database. These
sources, in turn, are relied upon in secondary documents cited such as the
National AIDS Strategy for the United States and the Southern AIDS Coalition
Manifesto and Update.

[8]
CDC, HIV/AIDS Surveillance Report ,2007; for comprehensive discussions of
disproportionate impact of HIV/AIDS on minorities in the south, see, Southern
AIDS Coalition, “Southern States Manifesto: Update 2008, HIV/AIDS and
Sexually Transmitted Diseases in the South, July 21, 2008; Sutton, M., et al,
“A review of the Centers for Disease Control and Prevention’s
Response to the HIV/AIDS Crisis Among Blacks in the United States,
1981-2009,” American Journal of Public Health, (2009) 99:No. S2, pp.
351-9; CDC, HIV/AIDS Epidemic and HIV/AIDS Prevention in the Hispanic/Latino
Community: Consultation with Leaders from the Hispanic/Latino Community, April
2008.

[9]
Southern AIDS Coalition, “Southern States Manifesto,” p. 3. For
additional epidemiological data on HIV/AIDS in the southern US, see, Fleming,
P.L. et al, “The epidemiology of HIV/AIDS in women in the southern US”,
Sexually Transmitted Diseases July 2006: 33(7) pp. S32-38; Reif,S. et al,
“HIV Infection and AIDS in the Deep South,” American Journal of
Public Health, June 2006: (96) 6: 970-3. For an analysis of HIV and human
rights in the South, see Human Rights Watch, “Southern Exposure: HIV and
Human Rights in the Southern United States,” New York, November 2010.

[15]
Office of National AIDS Policy, National AIDS Strategy for the United States,
p. 7. “In care” for HIV is defined by the US Health Resources and
Services Administration (HRSA) as receiving a minimum number of viral load and
CD4 tests during a one-year period. See, HRSA, “A Practical Guide for
Measuring Unmet Need for HIV-Related Primary Medical Care,” http://hab.hrsa.gov/tools/unmetneed,
(accessed January 4, 2011).

[16]
Whetten, K.et al, “Overview: HIV/AIDS in the Deep South Region of the
United States,” AIDS Care 2006; 18 (Supp.) 51-55. Whetten defined
Alabama, Georgia, Louisiana, North Carolina, South Carolina and Mississippi as
the Deep South.

[17]
Kaiser Family Foundation, “The HIV/AIDS Epidemic in the United
States,” September 2005.

[32]
Denning, P. et al, “Communities in Crisis: Is There a Generalized HV
Epidemic in Impoverished Urban Areas of the United States?” National
Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, July 2010.

[44]
Mississippi Comprehensive State HIV/AIDS Plan, p. 7; Human Rights Watch
interview with Craig Thompson, Director, STD/HIV Office, Mississippi State
Department of Health, Jackson, Mississippi June 22, 2010. Mr. Thompson
explained that while the Department of Health had verified and reported the 50
percent figure, a recent internal survey had placed the unmet need in the range
of 70 percent, a figure which the Department was attempting to verify. Mr.
Thompson resigned as Director on September 30, 2010, and was replaced by Dr.
Nicholas Mosca effective November 1, 2010. According to the US National AIDS
Strategy one-third of persons infected with HIV are not in care. National AIDS
Strategy, p. 7.

[46]
President’s Emergency Plan for AIDS Relief (PEPFAR) FY 2008 Country
Profiles for Botswana where 52 percent of people living with HIV are not
receiving “care and support services” ), Ethiopia (56 percent), and
Rwanda (41 percent). PEPFAR defines care and support to include not only
medical treatment for HIV but a range of services that include testing but also
TB screening , prevention education and other services at an identifiable
clinic site. The HRSA definition of “in care” is more narrowly
limited to those who have undergone a quarterly CD4 or viral load test in the
past 12 months.

[62]
International Covenant on Economic, Social and Cultural Rights (ICESCR),
adopted December 16, 1966, G.A. Res. 2200A (XXI), UN GAOR (no. 16) at 49, UN
Doc. A/6316 (1966), 99 UNTS 3, entered into force January 3, 1976, signed by
the US on October 5, 1977; Committee on Economic, Social and Cultural Rights,
General Comment No. 14, The Right to the Highest Attainable Standard of Health,
UN Doc. E/C.12/2000/4, adopted August 11, 2000, para.12.

[67]
Ibid; CMS, “Medicaid Eligibility: Are You Eligible?” Kaiser
Commission on the Uninsured, “Challenges of Providing Health Insurance
for Parents and Children in a Recession: A 50 State Update on Eligibility
Rules, Enrollment and Renewal Procedures and Cost-Sharing Provisions in
Medicaid and SCHIP in 2009,” January 2009.

[68]
Kaiser Family Foundation, statehealthfacts.org, “Income Thresholds for
Jobless and Working Parents Applying for Medicaid by Annual Income as a Percent
of Federal Poverty Level, 2009,” http://www.statehealthfacts.org/comparetable.jsp?ind=205&cat=4
(accessed October 25, 2010).

[69]
Social Security Act, Section 1115 (a) 1 authorizes the Secretary of Health and
Human Services to waive certain requirements for Medicaid when petitioned by
the states. This provision has been used by two states to expand Medicaid
eligibility to non-disabled people living with HIV, with state dollars matched
by federal funds. See Treatment Access Expansion Project, Harvard Law School,
“How to Use a 1115 Medicaid Waiver as a Bridge to 2014 for People living
with HIV and AIDS,” November 2010.

[104]For example, Title
VII of the Civil Rights Act of 1964 prohibits employment discrimination based
on race, color, religion, sex, or national origin.

[105]Title I and Title V
of the Americans with Disabilities Act of 1990, as amended (ADA) prohibits
employment discrimination against qualified individuals with disabilities in
the private sector, and in state and local governments.HIV is considered a
“disability” under the meaning of this section. See, ADA Amendments
Act of 2008, Public Law 110-325; Couture v.Bonfils, USCA 10th Circuit 2005.

[125]
Greenwald, R., “Health Care Reform: Updates to Federal Efforts to Improve
Access to Care for People Living with HIV/AIDS,” Treatment Access
Expansion Project, Harvard Law School, April 12, 2010.

[126]
Public Citizen Health Research Group, “Unsettling Scores: A Ranking of
State Medicaid Programs” April 2007,p.82.

[127]
Kaiser Family Foundation, statehealthfacts.org, “Income Thresholds for
Jobless and Working Parents Applying for Medicaid by Annual Income as a Percent
of Federal Poverty Level, 2009,” http://www.statehealthfacts.org/comparetable.jsp?ind=205&cat=4
(accessed October 25, 2010).

[146]
Patient Protection and Affordable Care Act, signed into law March 23, 2010
(Public Law No. 111-148); Health Care and Education Reconciliation Act, signed
into law March 30, 2010(Public Law 111-152).

[148]Holahan J. and Blumberg L., “How Would
States Be Affected By Health Reform?” Urban Institute, January 2010;
Kaiser Commission on Medicaid and the Uninsured, “Briefing on State
Medicaid Programs, the Recession and Health Reform,”
http://www.kff.org/medicaid/Briefing-on-State-Medicaid-Programs-Recession-Health-Reform.cfm(accessed
November 15, 2010).

[149]Social Security Act, Section 1115 (a) 1
authorizes the Secretary of Health and Human Services to waive certain
requirements for Medicaid when petitioned by the states. This provision has
been used by two states to expand Medicaid eligibility to non-disabled people
living with HIV, with state dollars matched by federal funds. See, Treatment
Access Expansion Project, Harvard Law School, “How to Use a 1115 Medicaid
Waiver as a Bridge to 2014 for People living with HIV and AIDS,” November
2010.

[164]
The right to education, recognized in the Universal Declaration of Human Rights
and other international instruments, encompasses effective health education. The
Committee on Economic, Social and Cultural Rights has interpreted article 12 of
the International Covenant on Economic, Social and Cultural Rights to obligate
states to take steps necessary for the “prevention, treatment and control
of epidemic, occupational and other diseases”, including the
“establishment of prevention and education programmes for
behavior-related health concerns such as sexually transmitted diseases, in
particular HIV/AIDS, and those adversely affecting reproductive health.” General
Comment No. 14, The Right to the Highest Attainable Standard of Health,
Committee on Economic, Social and Cultural Rights, 22nd sess. 2000,
para. 16.

[165]
Human Rights Watch, The Less They Know, the Better: Abstinence-Only HIV/AIDS
Programs in Uganda, New York, March 2005, http://www.hrw.org/en/node/11803/section/1
(accessed October 25, 2010); Human Rights Watch, Ignorance Only: HIV/AIDS,
Human Rights and Federally Funded Abstinence-Only Programs in the United States,
New York: September 2002.

[166]
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Title
5, Section 510.

[167]
SIECUS, “SIECUS State Profiles: A Portrait of Sexuality Education and
Abstinence-Only-Until Marriage Programs in the States” July 2010.However,
funding for abstinence-only education was attached to the health care reform
legislation enacted in March 2010. Patient Protection and Affordable Care Act,
signed into law March 23, 2010 (Public Law No. 111-148); Health Care and
Education Reconciliation Act, signed into law March 30, 2010(Public Law
111-152).

[168]
See, e.g. Mathematica Policy Research, Inc. for the US Department of Health and
Human Services, Impacts of Four Title V, Section 510 Abstinence Education
Programs, Final Report, April 2007.

[216]
Center for HIV Law and policy, Positive Justice Project, Ending and Defending
Against HIV Criminalization: A Manual for Advocates, State and Federal Laws and
Prosecutions, First Edition, Fall 2010.

[247]
International Covenant on Economic, Social and Cultural Rights (ICESCR),
adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 UN GAOR (no.
16) at 49, UN Doc. A/6316 (1966), 99 UNTS 3, entered into force January 3,
1976, signed by the US on October 5, 1977; Committee on Economic, Social and
Cultural Rights, General Comment No. 14, The Right to the Highest Attainable
Standard of Health, UN Doc. E/C.12/2000/4, adopted August 11, 2000, para. 11.

[254]
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